Cases from the Community: Investigators Provide Their Perspectives on the Practice Implications of Emerging Clinical Research — A Special Video SupplementCase discussion: A 51-year-old woman with strongly ER/PR-positive, HER2-negative BC and 12 of 12 positive nodes
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TRANSCRIPTION:
DR LOVE: Fifty-one-year-old woman with a 3-cm, strongly ER/PR-positive, HER2-negative, clinically negative axilla, but her PET/MRI shows increased uptake in the spine and marrow changes without FDG activity. So myeloma was ruled out. The question is, what’s going on? So this patient actually went to surgery and had a mastectomy. But at the time, they did a core biopsy of the iliac crest that proved to be positive for metastatic disease. She actually had 12 out of 12 positive nodes at surgery. And I kind of wonder about maybe whether she actually should have had it. But in any event, the question is at this point, how should this patient be treated? DR O’SHAUGHNESSY: She’s 51, so she may be perimenopausal even if she had stopped menstruating — I still wouldn’t trust her ovaries. If they’re intact, even if you haven’t menstruated in 5 years, being 51, we don’t have really good assays to be definitive that she’s postmenopausal. So I would be wanting to make her postmenopausal, because I would be giving her first-line letrozole and palbociclib as therapy. So I would start off with an LHRH agonist added. Then I would go on to BSO once she recovered from her surgery. I would certainly give her an osteoclast inhibitor agent, certainly. It’s hard to know about the local control issues, Neil, in these situations. Gosh, with 12 positive nodes, I guess I’m kind of happy she had the surgery, because boy, it could be many years down the road, but down the road she would be at risk for some pretty morbid recurrence there. I probably would not do radiation therapy at this point in terms of postmastectomy radiation therapy. But I think I individualize. If somebody is at risk down the road for a very severe local problem, I at least think about it, although I do think we see some remarkable responses with either endocrine therapy alone or endocrine therapy plus palbociclib. And if you’re patient and wait, even up to a year, you can get some unbelievable responses in the local-regional disease. And you can, of course, keep a very close eye on it and consider surgery later on, if things are starting to progress, et cetera. So there’s no right or wrong way to go. I don’t think we have data that there’s going to be a systemic benefit from the patient, from taking care of her local disease versus not. I’m not convinced the data are showing us that there’s a survival advantage to doing surgery on patients, even with locally advanced disease, who present with metastatic disease. |